Submission to the TDHBOn the Maternity Facilities Review

from: Dr Keith T Blayney MBChB; DipObst; FRNZCGPFebruary 2004

A "Discussion Document on the Future of Maternity Facilities in Taranaki" supposedly based on the recommendations of an "Independent Review Maternity Facilities Taranaki" report (hereafter the "Report") identifies a number of options for the Board to deal with an apparent crisis of excess maternity capacity. This submission looks critically at the Review, the Document and a number of other papers on the subject and (hopefully) adds some balance to the whole process.

My perspective is medical and scientific, as that is my background, and while admittedly my understanding of the financial aspects is less qualified, it is not without the governance experience provided by membership on a number of boards and committees. As one of the few General Practitioner Obstetricians remaining in the country, it could be misinterpreted that I have a biased and "vested interest" in this matter, but it doesn't take a mental giant to realise that the maternity changes that led to the mass exodus of GPs indicates that providing maternity care in the General Practice setting is no longer economically viable, so I must be continuing for altruistic reasons (well, I can't think of any selfish reasons!).

[A] Summary of the Submission to the TDHB on the Review of Maternity Facilities in Taranaki Dr K T Blayney MBChB; DipObst; FRNZCGP

This submission first looks critically at the "Independent Review Maternity Facilities Taranaki" and concludes that it was not particularly "Independent" nor objective. Significant errors and omissions in this Report include:

The total disregard for the existence of an experienced General Practitioner Obstetrician (GPO) Lead Maternity Carer (LMC) in Hawera.

The failure to note the rising Birth Rate for Stratford & Hawera.

Little recognition of the relevance of a significantly higher Fertility Rate in South Taranaki.

No recognition of a much higher proportion of Maori in South Taranaki compared to the rest of Taranaki and how that affects Fertility Rates.

The unproven assumption that future Birth Rates will fall because there is a reduction in women in the fertile range, ignoring the likely cause of career minded women (who tend to delay childbearing) being forced to seek tertiary education away from South Taranaki and ignoring the very high proportion of females under 15 in South Taranaki in 2001, indicating a significant increase in future birth numbers, as we are already starting to see.

Failure to link the low average length of stay (ALOS) and higher occupancy for Hawera to the inability for Hawera to absorb extra women from Stratford or Wanganui.

No statistics given on how many days Hawera is at or above capacity, nor on the caseloads of midwives at one facility compared to another.

A serious misinterpretation of the Cochrane Review of early post-natal discharge, used to support a policy that is NOT evidence based and which has, at least in part, created the apparent excess capacity.

No recognition that Hawera LMCs have access to blood bank facilities and emergency support by the resident GPO for procedures such as forceps and repair of maternal birth trauma.

An amazingly inaccurate claim that the close proximity of the two primary care facilities, particularly "on the same direct route" is unusual, and that the author knows of no similar example. Te Kuiti, 30 minutes from Te Awamutu, itself 30 minutes from Hamilton is an obvious one in her own area she missed. Further examples follow in the next section.

However, the Report gives support for the retention of the Hawera Unit:

In all audit areas explored by the Report (other than user-friendly space), the Hawera Unit equals or exceeds standards at the other Taranaki Maternity units, including ALOS, Occupancy, Service User Outcomes, Baby Friendly Initiative, Provider Quality Specifications and General Observations.

The first six of the nine recommendations of the Report focus on areas the other two units need to achieve to match Hawera's standard. Recommendation 7 is aimed at improving Midwife numbers. Recommendation 8 advises the Board to view the Hawera Maternity as the "preferred primary care facility" if "rationalisation/consolidation" is planned and Recommendation 9 advises wide consultation in that planning.

Next, the Discussion Document produced by the TDHB management is strongly criticised for an almost total disregard of the Report and its recommendations while promoting a service reduction agenda not supported by the facts. In its "Summary of review findings" it mentions only three points, and it misquotes and misunderstands the first two:

It claims the Taranaki Birth Rate was declining, while the Report actually stated it was relatively stable. Both confuse Birth Rate with Birth Numbers as Birth Rates are HIGHER if the numbers of births are stable with a reducing population. It accepts the projected decline without question.

It claims the primary facilities are unusually close to each other and to Base, whereas the Report only implied the primary facilities were unusually close. Both claims are refuted by the simple process of listing a multitude of primary maternity units as close or closer to their Base and identified units "on the same route". I didn't bother to list all the units closer to each other but not "on the same route".

The Discussion Document introduces new birth numbers, either not shown or conflicting with those in the Report suggesting a greater drop in numbers but not separating Hawera from Base numbers. However the numbers for the most recent years suggest the drop was occuring at Base, not Stratford (static) or Hawera (rising numbers).

At the Public Consultation Meeting, Hawera 22/1/04, previous acting General Manager of Funding and Planning Kevin Simpson presented his summary of the Review with a new third set of birth numbers covering different year definitions. He claimed the Birth Rates have declined (I presume he meant Birth Numbers and only at Base as these new figures also show Hawera and now Stratford numbers rising), that Maternity Facility capacity is greater than demand (which is not true for Hawera) and that Total Maternity Costs are increasing. The graph showing an apparent alarming cost rise is a false illusion (as the cost axis doesn't start at zero) and analysis of the figures show very modest (3.5% and 1.7%) rises in the last two years, which virtually disappear when adjusted for inflation.

Annual, Strategic and Pisk Plans accepted by the TDHB appear to commit the Board to maintaining the viability of both Base and Hawera hospitals (inclusive of 4 maternity beds) and public expectation is that they will at least maintain their present service levels. Reducing facility capacity is unlikely to produce significant savings, but could compromise the viability of the Hawera Hospital as a whole. Major cost reductions are far more likely to occur following rationalisation of the need for maintaining high numbers of staff supporting the "Medical Director" (127), "Board Management/Corporate" (182) and the 126 "Mental Health Workers" (mostly low skilled as there is a shortage of highly skilled Mental Health Workers).

The Public Health Intelligence paper on Taranaki fertility confirms the high fertility rates in South Taranaki but it overlooks patient flows to Whanganui, adding to the confusion of a document with too much data but little meaningful summation. However, armed with a calculator, one can identify useful district information.

A set of seven recommendations to the Board is made, that go beyond the last option in the Discussion Paper (retain the Status Quo). These recommendations are likely to satisfy both the needs of the Central and South Taranaki communities and save the TDHB significant revenue.

[B] The Independent Review Maternity Facilities Taranaki:

[A1] Authorship:

The "Independent Review" was prepared by Helen Wood-Rowe from HealthShare Ltd. She is the Manager of Audit and Quality at HealthShare Ltd, and holds the qualifications: RGON, RM, BSocSc, MBA [1], so she is a Midwife with Social Science and business management qualifications.

HealthShare Ltd is a "shared services agency" of the District Health Boards of the previous Midlands Regional Health Authority.

A review prepared by a manager -with a nursing/midwifery background- of an organisation partially "owned" by the very DHB she is reporting to cannot be described as "independent" by any stretch of the imagination, even if Helen herself tried to be unbiased.

[A2] Critique of Report:

Scope of the Review
As the sole remaining GP Obstetrician with a Lead Maternity Carer (LMC) access agreement to the Hawera Maternity unit, I would have expected to be considered as a stakeholder (along with the patients I deliver). This was not the case, as only some LMC midwives were approached. Any consideration on the delivery of maternity services in South Taranaki is flawed if it does not at least consider the medical and emergency backup function of an experienced local GP Obstetrician [2].

Review Methodology
As in the "Scope" section, there was no intention to interview medical LMCs, specialist or GP, despite the author being informed that a GP Obstetrician was one of the LMCs and provided some emergency back-up. This results in erroneous interpretations of research findings and safety aspects of maternity services in Taranaki, as well as placing the whole report's validity and independence in further doubt.

Background
It is claimed in 3.2 that "the Taranaki birth rate has remained relatively stable over the last two years", and suggests that as the fertile female population is declining, a "corresponding decline in the birth rate is expected". It is this interpretation that has helped fuel the management push to reduce the service capacity, yet it is a quite incorrect interpretation, not just because the decline is "subject to confirmation". One should note that:

it is the total numbers of births in Taranaki that has remained stable. The "Birth Rate" is defined as births per 1,000 population , so as this population has reduced, the Birth Rate is actually increasing!

the numbers of births at Hawera has increased 15% from 2001/2 to 2002/3 at a time population trends are suggesting the number of females 15-44 are falling (along with the total population) in South Taranaki, so again, this tells us the Birth Rate for South Taranaki is increasing significantly.

and the reason for the higher Birth Rate? If the population base is smaller but the birth numbers are stable or (in the case of Hawera) rising, the Fertility Rate a.k.a. the Age-Limited Birth rate (the number of live births per 1,000 estimated mean number of women aged 15-49 [4]) in Taranaki, particularly South Taranaki must be rising. The higher General Fertility Rate for South Taranaki women aged 15-44 is confirmed in the Ministry Paper on Taranaki Fertility now available on the TDHB web page [11] where it shows 28.4% of births within the TDHB area were domiciled in the South Taranaki constituency (if one adds up the Census Area Unit numbers), which has only 12.3% of the fertile women (according to the Report) and 26% of the population, according to the 2001 census [4]. This paper was available to Helen [13] (who in fact requested it), but the results not admitted to. In other words, South Taranaki women are having bigger sized families than in other parts of the country and certainly more than in the rest of the Taranaki province, but the Report knowingly ignored this conclusion.

Findings
In 4.2 Future Birth Rates a lot of emphasis is placed on the apparent fact that the number of women in the 15-44 (fertile) age range seems to be falling, with the implication that therefore, the number of babies born will be less. The fact that Taranaki's Fertility Rate (births per woman) of 2.25% is higher than the replacement level of 2.2%, while the national average is below it, clearly more than compensates for fewer women in the child bearing age. Put simply, there may be fewer women having children but they are having more to make up for this!

The Maori Fertility Rate is not mentioned, but the national rate was 2.38 in 1995 [3], thus more maternity services are likely to be needed where the proportion of Maori in the population is higher, as in South Taranaki (19.1% compared to 12.8% and 9.25% in the New Plymouth and Stratford Districts respectively [4]).

The reason why South Taranaki has seen such a big drop in the proportion of females 15-24 in the last 10 years was not explored. The most likely explanation is the now total lack of any Tertiary education facilities in Hawera, so all Polytech, Nurse and Teacher training and all University education requires a move out of the district, as supported by the fact that males of a similar age have reduced numbers (see graphs below). As these young women are likely to be entering a career, they are less likely to become pregnant than similar aged women remaining in South Taranaki but by their mid 30s many may have returned which is reflected in the increased births seen in the older age groups. Furthermore, as fewer Maori women seek tertiary education (as seen by a smaller drop in the 15-44 age for Maori) and begin having children at a younger age than Pakeha (as well as having more) [6], the higher Maori population in South Taranaki will further buffer the "projected decline" in births in Hawera.

This demographic anomaly is emphasised in the Report and used to predict a future reduction in Birth Rate (or even Birth Numbers) but no attention was given to the much larger numbers of girls under 15 "coming through", particularly in the Maori population. The 2001 Census reveals that 39.0% of Maori people and 25.5% of all people in the South Taranaki District are aged under 15, compared with all New Zealand totals of 37.3% (Maori) and 22.7% for all people [4].

Thus South Taranaki has a higher proportion of girls just under the fertile 15-44 ages than elsewhere indicating that our "Future Birth Rate" and (providing the Fertility Rate stays up) the "Future Birth Numbers" will increase rather than fall. This is clearly shown on the demographic charts for South Taranaki. What is more, this increase is already showing up with increasing birth numbers at Hawera over the last few years.

In 4.3 Average Length of Stay it is noted that Hawera has the shortest ALOS, even compared to normal deliveries at TBH. What isn't noted is that this means that at times when the requirement for beds at Hawera exceeds its capacity of four, it is less likely that room can be made by an early discharge of a current mother and baby than in other facilities as we are already achieving an ALOS of 48 hours. This argues against any reduction in capacity at Hawera, and against any closure at Stratford as Hawera may often be unable to cope with extra numbers from Central Taranaki.

The statement implying that studies indicate early discharge does not predispose to adverse outcomes is a false interpretation of the review of studies on the subject, and this is frequently misquoted by management to support the policy. If the Cochrane Review is accessed on line [5] one can see that the Reviewers' conclusions are that "The findings are inconclusive" and that while "There is no evidence of adverse outcomes associated with policies of early postnatal discharge,....methodological limitations of included studies mean that adverse outcomes cannot be ruled out." Brown et al notes that "Large well-designed trials of early discharge programs incorporating process evaluation to assess the uptake of co-interventions, and using standardised approaches to outcome assessment are needed." This misinterpretation of a Cochrane review not only supports the concern that the Maternity Review may not be unbiased and "independent" but questions the wisdom of allowing management any influence over clinical policies such as the 48 hour discharge policy which has contributed to the apparent excess capacity in facility beds.

In 4.4 Occupancy annual and monthly figures are quoted, revealing Hawera has a consistently higher occupancy than Base Maternity, and both were 2-3 times that of ElizabethR. However, there is no information provided on how often Hawera is at full occupancy nor how often a woman has to transfer or stay at TBH because "there is no room in the Inn".

My personal observations and feedback from Hawera midwives is that full capacity is a relatively frequent occurance, and has occured in every month since moving to the new facility, but may only last a day or two. On the basis of these observations, I would strongly advocate for not only retaining the four beds but exploring ways to increase capacity at times, particularly if the facility at Stratford was removed by a shortsighted decision. When the new Hawera hospital was planned, I objected to having only four maternity beds but was promised by management that "flexible beds" could cover any unexpected high use. This has never been allowed but there remains the possibility that an extra bed could be placed in postnatal rooms with a mobile curtain between, effectively doubling the capacity of the unit, or better still, the maternity unit should be expanded to a more appropriate size.

In 4.5 Cost of Service it is indicated that the TDHB receives substantially more money (over double) for labour and delivery and postnatal services provided at maternity units having less than 199 births (like Hawera) than at larger units having more than 600 births (like Base Maternity) [Table 4]. Furthermore, the previous acting General Manager Funding and Planning (Kevin Simpson) confirmed at the public Consultation Meeting at Hawera on 22/1/04 that it cost the Board more to have normal deliveries at Base than Hawera. This suggests that it would be very costly if more women were forced to deliver at Base because of any lack of facility capacity at Hawera.

The Report then goes on to say "The current combined annual delivery total for Hawera Maternity and ElizabethR is less than 200. Therefore there would be no economies to be appreciated by combining the delivery volumes for the two sites." [pg10] This would indicate that it is not in the financial interest of the Board to close ElizabethR and have women travel to Base or Hawera. However the total postnatal stays is over the 200-volume threshold, but less than 200 per facility.

The cost of running each facility isn't compared, and understandably it would be difficult to compare a private birthing unit, a DHB run primary maternity unit (with an experieced GP Obstetrician) and a DHB primary and secondary maternity unit. However some attempt should have been made to identify the cause of the increasing cost to the DHB, and the cost consequences of any reduction of facility capacity at each unit. It is hard to see any cost benefit from a bed number reduction at Hawera as the minimum staff numbers (midwifery and support) would not change.

In 4.7 LMC Midwives it is implied that the case-load for midwives is too high for some. Some Hawera midwives admit to twice the case load recommended for rural midwives, making any further increase (by reducing services at Stratford) unwise.

In 4.8 Medical Support for Maternity Units the report again fails to note the 24/7 availability of an experienced GP Obstetrician for midwife back-up. By using the "Exceptional Circumstances" provision available to rural GP Obstetricians, I have been able to offer back-up emergency support to midwives at no extra cost to them [2]. This has primarily been used in the areas of forceps lift-outs and repair of significant birth canal tears ("stitches"), thus saving unnecessary transfers and future gynaecological problems, as well as significantly reducing the anoxic risk faced by a fetus with a prolonged second stage of labour. If this service is not seen as valuable, there would be little point in my continued involvement in obstetrics which is in fact a financial drain on my practice. However, feedback from local midwives and Base Obstetricians is that this service does make the Hawera Maternity Unit safer and reduces the workload at Base Hospital.

The local specialist Obstetrician and Gynaecologist Paul Dempsey identifies the increased call work since GPs were largely replaced by Independent Midwives as the main factor for his retirement from Obstetrics. He is quoted in the Daily News of 21/1/04 (pg2) "...a lot of the calls were about things that in the past the GPs could have handled". If the sole remaining GP Obstetrician is unable to provide back-up in Hawera because of reduced facilities, the work load for the specialist Obstetricians will increase significantly more.

"Current training of midwives is insufficient for them to deal with [all] emergencies when isolated from immediate specialist backup" [Referenced Maternity Document [6] Appendix 12: (Comparison of the core maternity principles with SWOT [†] analysis). While Ms Wood-Rowe may have missed or ignored this finding, it remains a factor when examining rural maternity services and adds support to the need for medical back-up at Hawera.† SWOT = HFA review of "strengths, weaknesses, obstacles and threats in the maternity system".

The reference to a two hour time interval between onset and death for postpartum haemorrhage (PPH) is confused. The actual quote is "With the exception of postpartum haemorrhage, the estimated average time interval from onset of an obstetric complication to death is more than twelve hours. Postpartum haemorrhage can cause death within two hours of onset but it is one of the major obstetric complications for which first aid can be provided in a primary setting." [6]. The ability for Hawera to provide blood transfusions makes a PPH at Hawera even less dangerous, but this is not acknowledged in the Report.

More worrying is the failure to recognise that the fetus does not have the 12 hours grace a mother may have and that there are many times when a fetus in distress can be saved from death or brain injury by expediting delivery. In Hawera, the experienced LMCs can identify fetal distress early and arrange a rapid transfer by ambulance to Base Delivery Suite or directly to the Caesarian operating theatre as appropriate, often faster than can be managed from Base Delivery suite (poor layout, varied experience of staff etc). Furthermore, if fetal or maternal distress occurs late in second stage, the delivery can be expedited in Hawera by the GP Obstetrician, reducing the risk to the fetus from an hour's further delay and avoiding an unnecessary transfer.

The quoted phrase "women resident in the catchment area of rural hospitals have fewer complications and similar foetal outcomes when compared with the rest of New Zealand" should not have been used as a direct quote, as while it has a somewhat similar meaning, the actual quote on page 25 of the Referenced Maternity Document [6] is "We expect 50 percent of women to be screened as needing to birth at a facility that has a secondary maternity service. There is evidence to suggest that the remaining 50 percent will achieve better health outcomes if they birth in primary facilities since it limits availability of surgical intervention. [Matheson, D and Borman, B. 'The patterns of use of facilities and obstetric outcomes for women living in rural areas'. Draft report for MOH, 1999]". The original wording is a much more powerful argument for retaining rural birthing facilities than the inaccurate quote used without comment on its relevance to the whole review!

In 4.9 Facilities, it was noted that the facility at the Hawera Maternity Unit is of a high standard, but noted the problems we face with limited storage space, night parking, inability to provide short-term ante-natal monitoring and limited bed capacity which I fully endorse and wish had been addressed better in the planning of the unit but we were strictly limited in space for reasons only known to management. This unit really needs to expand rather than face any further curtailment of capacity and if the option of doubling up beds in the current rooms is not acceptable for some reason, I would recommend to the TDHB that options for increasing the unit without compromising the medical/AT&R In-patient unit are explored. The most sensible option would be to expand the building somewhat to restore adequate capacity..

In 4.10 Service User Outcomes, 4.11 Baby Friendly Initiative, 4.12 Provider Quality Specifications and 4.13 General Observations the customer satisfaction, distance to travel, breast feeding rates, compliance with the BFI and other Quality criteria all support retention of at least the status quo for the Hawera Maternity Unit.

In 4.10.2 Distance to travel it is claimed that the close proximity of two primary care facilities is unusual, and in the only example the author could think of in the Midland region neither was on the same route. What about Te Kuiti with 2 maternity beds, 60 min from Hamilton via Te Awamutu with 9 maternity beds, 30 min from Hamilton? The author needs to get out a bit more, or at least do some basic research on other NZ maternity units. Admittedly this is difficult to do "on-line" as most DHB web sites concentrate on who is on their Board, what a wonderful job they are doing fulfilling PC requirements and how up-to-date their Base hospital is. In the Waikato site, for example, the only concession to the existence of the community "4 T hospitals" (Thames, Te Awamutu, Te Kuiti & Taumarunui) is a map! I have listed sufficient examples of similar close proximity maternity units in the Discussion Document Critique section below to demonstrate that this situation is far from "unusual".

Recommendations
The nine recommendations largely indicate areas of improvement needed at Taranaki Base Maternity and/or ElizabethR to match the high standard of Hawera. If primary maternity service facility "consolidation" is sought by the TDHB, it recommends Hawera as the "preferred primary care facility", although I doubt the author meant New Plymouth women should be expected to deliver at Hawera!

[C] Critique on the Discussion Document:

The Discussion Document on the future configuration of Maternity facilities in Taranaki (Dec 2003 - Feb 2004) is, according to the Media Release of 16 December 2003, a summary of the "Independent Review" discussed above. In reality, this is a management paper that at best misinterprets the Report and at worst actively misdirects the public and the TDHB towards a service reducing agenda that we thought had ended with the departure of certain management figures. It concentrates on only a few findings, totally ignores the nine recommendations, introduces new concepts and figures not provided in the Report, then essentially asks which area of service provision should be reduced.

Summary of review findings

"The Independent review determined that Taranaki has a declining birth rate which is projected to decline further in the future due to a decreasing number of women in the 15-30 years age group, particularly in the Stratford and South Taranaki areas."

This statement is not only a misquote, but is totally erroneous. The Report claimed that "The Taranaki birth rate has remained relatively stable..." [3.2]. However, I have demonstrated that the author of the Report did not seem to appreciate that the term "Birth Rate" is defined as births per 1,000 population (the Crude Birth Rate is "The number of live births per 1,000 estimated mean population" [4]) so that she actually meant "total birth numbers". The actual birth numbers have remained static for Base Maternity and ElizabethR in the last 2 years but increased by 15.4% for Hawera (117 up to 135) [4.1], even in subsequent altered figures. The Birth Rate, however, has gone up because the population has declined somewhat (the same or greater births by fewer people).

Still don't understand?

A Birth Rate is like a speed. If you travel 100km in 1 hour your speed is 100km/hr, if you then travel the same distance (100km) in 6.46% less time (56 minutes 7 seconds), one must be travelling faster, at 100km per 56.12/60hour = 107km/hr
If you have say 70 births for 9,500 population, one has a Crude Birth Rate of 7.4 per 1,000. Then the population drops to 8,886 but one still has 70 births, so the Crude Birth Rate is now 7.9 per 1000. This is the situation in Stratford. If you have the same number of births in a smaller population size the Birth Rate for that population is higher.

"It is unusual to have two primary care facilities in such close proximity both to each other and to a primary /secondary care maternity facility (Base Hospital at New Plymouth)".

This is again a misquote as the Report stated only "The close proximity of two primary care facilities is unusual..." It didn't say the proximity to a base unit was unusual.
Nevertheless, neither situation is that unusual as I have shown here:

Birth volumes
The discussion document here provides information not in the report, namely birth numbers as far back as 1996 showing a 500 drop in total numbers from 1761 to 1261. However, it has some features that do not generate confidence in this document, namely:

It combines Base and Hawera numbers pointlessly. If one is asked to discuss the birthing facilities, it is not unreasonable to separate out each facility's numbers.

The total numbers for the last two years do not match those given in the Report, but the Stratford numbers do, so presumably these are TDHB financial year (July 1 to June 30) figures. If the 2003 figure of the Report is used, the drop is 446 (25%) and most recently have exclusively occurred at Base.

The numbers at ElizabethR have remained static, so it is Base and/or Hawera that is having fewer deliveries. According to the Report, Hawera numbers have increased by 15.4% [4.1] in the last year, so at least recently, the reducing numbers of births must be occuring at Base.

Options
The benefits and disadvantages for four maternity service options are given:

Cease at Hawera: Financial savings are claimed but not defined. There would be serious costs to providers, patients and their families that I suspect would outweigh Board savings. Increased flows to Wanganui are not a "risk", if Wanganui provides the service, it gets the money, the TDHB cannot expect to get paid for services it won't provide.

Cease at Stratford: It is claimed Hawera can absorb some volumes, this is often not true, whether one is considering availability of beds or LMC providers. Similar arguments on community costs exist.

Cease at Hawera and Stratford: How can there be "significant financial gain"? The national fees for labour and delivery and for postnatal services are half that at Base than for the same service provided at Hawera and I am told the Base beds are more expensive to run. The community costs are considerable. The TDHB would face massive community backlash with enormous costs and loss of all trust built up over the last few years.

Status Quo: Nowhere in the Report or Discussion document has the stated waste and duplication been documented. How can an uncapped contract in Stratford be a significant risk??? Is the TDHB management worried that Stratford women are suddenly going to breed like rabbits? If the concern is that the high ALOS at Stratford costs the Board more, why not renegotiate the contract with ElizabethR to provide a standard fee whatever the LOS and let the providers ensure stays are appropriate?

[D] Public Consultation meeting, Hawera 22/1/04:

The previous acting General Manager of Funding and Planning Kevin Simpson presented his summary of the Review, but with some "corrected" figures. Of significance we heard that:

Mr Simpson believes the "birth rates" in Taranaki were declining, however, the figures he gives reveal static birth numbers in the last three years (so the birth rate is rising in the last three years). He probably meant birth numbers, but his graphs show the decline in birth numbers has stopped, and reversed for Stratford and Hawera.

Mr Simpson believes the Maternity Facility capacity is greater than demand. However, in Hawera the demand sometimes exceeds the capacity.

the Birth numbers he presents are for the calendar year, and do not seem to include women transferred in labour, so are not really comparable to the financial year inclusive of transfers in labour figures given in the Report BUT both show increasing birth numbers for Hawera and static levels for Taranaki in the last few years. The Hawera Birth Register lists 27 transfers in labour July02-June03 and 30 for Jan03-Dec03, clearly the explanation for why Mr Simpson's figures are about 30 lower than those in the Report.

Mr Simpson believes that the total maternity costs are rising. However, the "y-axis" (cost) of the graph he presents does not start at zero (which gives the impression of a much greater difference than is actually present). When one looks at the figures, the costs have gone from around $2,900,000 in 2001 to $3,000,000 in 2002 (a 3.5% increase) to approximately $3,050,000 in 2003 (a 1.7% increase), neither figure exceeding the annual increase in government funding to the TDHB and both approximating the CPI. Therefore contrary to his claim, maternity costs are fairly static, allowing for inflation! Furthermore, the "Total Maternity Costs" given appear to include secondary as well as primary costs, as the average annual primary "revenue provided" as listed on the TDHB website is $1.7 million [12]. This is an astounding misuse of figures to suggest to the Board and the public that a problem exists when it doesn't.

It is disconcerting to discover that every statement made to justify the review is incorrect, although Mr Simpson is correct in stating "we need guidance about community expectations and priorities".

[E] TDHB commitments in Annual, Strategic and Pisk Plans:

In 2001 the TDHB received approval from the Ministers of Health and Finance to proceed with the construction of a $7.9 million 26 bed hospital at Hawera to include a 4 bed maternity unit. The Board subsequently engaged Dr Dennis Pisk to provide an Independent report on the appropriate medical services at this hospital. On 28th February 2002 the full TDHB endorsed the Pisk Report which described a configuration of 28 beds, four of which were Maternity [8] pg17, and requested management to immediately implement Stage 1 of Option 3. Attempts to reduce the maternity capacity would be contrary to the Pisk Plan and may well influence the viability and efficiency of the Hawera Hospital as a whole.

The District Annual Plan 2003-6 (DAP) noted an "ongoing expectation to maintain present service levels across two hospital sites" [9] pg5 and

"At Hawera, while small scale leads to certain unavoidable inefficiencies there is the ongoing requirement to ensure that the hospital is capable of effectively meeting the basic health needs of the local community in a manner that is clinically and economically sustainable". [9] pg8

Both the DAP and the District Strategic Plan (DSP) describe one of the particular "Values (O matou uara) [of] the Taranaki DHB ... [to include] Open and honest communication." [9] pg15c[10] pg10c, yet both the "Independent Report" and the "Discussion Paper" are wildly inaccurate and knowingly withhold important and valid information. To do so doesn't fit well with the Board's stated value.

The DAP repeats the incorrect interpretation of statistics, namely "In light of the region's declining population and birth rate" [9] pg97. The authors of the DAP clearly don't understand the definition of "Birth Rate" (or realise that it is rising), and use it when they should be using "birth numbers" (which are rising in Hawera, static at Stratford but dropping at Base).

As the Board is expected to make financial savings, and reducing maternity capacity is unlikely to produce this, staff numbers may have to be reviewed. The DSP provides an enlightening Workforce Profile [10] pg28-29 revealing that in 2001 the provider arm of the workforce of 1,119 had 623 staff providing "Hospital Services", 59 providing "Public Health Services", 2 supporting "Nursing Director", 127 supporting "Medical Director", 126 "Mental Health" workers and 182 in the "Board Management/Corporate Support" category. There seems to be an awful lot of Mental Health workers despite both the DAP & DSP noting a need for "recruitment and retention of skilled mental health workers in the region" [9] pg22[10] pg17. I suspect the Board could benefit from removing most of the non-evidence based counsellors so it could afford to offer better renumeration to retain skilled psychologists and psychiatrists. How many of those supporting the Medical Director are clinical and how many are management isn't clear but the 182 management/corporate support number is incomprehendable and clearly long overdue a review by a truely independent source, preferably from an efficient private organisation, not another management heavy public corporation.

[F] The General Fertility Rate distribution for the TDHB

Click mapto enlarge

The TDHB Web site [12] has posted a rather complex document titled "The Distribution of the General Fertility Rate (per 1000) by Census Area Unit for Taranaki DHB (July 2001 - June 2003)" [11] produced by the "Public Health Intelligence" of the Ministry of Health. This document provided confusing data about women delivering in Taranaki but domiciled outside (the five from Mahoenui stumped them, not knowing it was just outside the Awakino Gorge) and even more confusingly, it did not discuss the Taranaki domiciled women delivering outside Taranaki. However, after communicating with one of the authors (Paul White), a simplified version addressing only Taranaki women delivering in Taranaki was produced, which I have posted here with his permission.

In both papers, one is able to identify areas on a map of Taranaki (pg 4) of high fertility (Waitara and futher north, and most of South Taranaki). Although the paper doesn't discuss the reason for the apparent extremely low Fertility Rates for Waverley, Waitotara and Makakaho, this is obviously because women from here tend to deliver at Whanganui Base and so their births are not documented in this study. The correspondingly low apparent GFRs occur because these women are actually delivering at Whanganui.

However, if one takes the "Appendix - Distribution by Births by CAU" figures (Table 2 in original document) and adds up the South Taranaki domiciled births, one can see that 28% of the Taranaki births (351 av. per year) are domiciled in South Taranaki, whereas only 26% of fertile women live in South Taranaki. Furthermore, if one adds the "60-80" women delivering at Wanganui which are not listed in this paper, the South Taranaki proportion would be about 32% of Taranaki births, consistent with a very high fertility rate.

One would expect approximately 50% of these to be suitable for delivery in a primary maternity unit [6] pg25 that is, 175. As we currently have around 105 women delivering and a further 30 transferring, there is a total of 135 women/year planning a Hawera birth which is 40 short of the theoretical 175. This 40 represents those women inappropriately delivering at Base (by choice or by perception that a Base delivery is safer). Should those 40 plus the "60-80" currently electing to deliver at Wanganui all want to deliver at Hawera in the future, the facility would be unable to cope.

[G] Recommendations to the TDHB in this submission by Dr Keith Blayney:

As Hawera is often at its capacity of four, if any reduction in Taranaki maternity capacity is decided upon, it should be found elsewhere (Report recommendation 5.8).

As the funding of facilities is at a higher level for smaller facilities, any reduction in capacity should be found at Base Maternity if the object is to save money.

There is little if any justification for reducing capacity at Hawera (nor at Stratford) on the basis of Birth Rate figures (which are in fact rising), birth numbers (rising at Hawera), future birth numbers (high proportion of under 15 girls) or mythical "financial savings". In fact, the inflation adjusted Maternity Costs are fairly static indicating the whole Review process has been unnecessary and a waste of time and money.

There is justification for increasing the capacity at Hawera and the TDHB should explore options for increasing both the bed and LMC capacity for the Hawera Maternity unit (including physically expanding the unit) without compromising the adjacent medical/AT&R In-patient facility.

The TDHB would be advised to avoid paying too much attention to management papers discussing important, simple concepts like "Birth rates" and "Total Maternity Costs" that management do not seem to understand themselves, or if they do, they have used inappropriately. Presenting basic statistical information like accurate Birth Numbers seems to be beyond their capacity.

There is a significant potential for "financial savings" by stopping management paying outside consultants to provide half-baked reports that they ignore anyway. Clearly the TDHB has an excess capacity of managers which should be reduced to the absolute minimum to run the Board's business efficiently and not waste time on silly reports like this.

Given the high numbers of management support staff identified in the District Strategic Plan it is timely to have a truely independent and objective review of management function, renumeration and numbers. This review must be by a private and profitable organisation with a streamlined management structure (not another overmanaged public organisation) and must finally separate out clinical from management employees and how much each costs. It should also look at the practicality of establishing a capped management budget to encourage administrative efficiency.